I. Identifying Information

Please complete this section so that the Welfare Peer TA Network can contact you if more information is needed.

Title:

*First Name:

*Last Name:

*Position Title:

*Agency/Organization:

Address:

*City:

State:

Zip Code:

Province:

Country:

*Phone:

Fax:

*E-mail Address:

E-mail addresses gathered by the Welfare Peer TA Network are neither sold nor distributed to other organizations.

II. Background of Agency

Please indicate the type of agency you are with and the geographic area(s) served by your agency.

Type of agency:

      State TANF Agency
      County/Local TANF Agency
      Other Public Agency , please indicate:
      Community-based Organization
      Other , please indicate:

Geographic area(s) served by your agency (select all that apply):

      Urban
      Rural
      Suburban
      Tribal
      Statewide
      Other , please indicate:

III. Description of the Innovative Program

Please use this as a guide. Describe the program you are nominating as an emerging innovation here by providing the following information.

*Program name:

Date of program inception, or duration dates of program:

*Type of agency/organization coordinating/operating the program:

Funding sources:

*Clientele/population served:

*Mission/goal of the program:

*Programs/services offered:

Evaluation results, performance measures, or how you know the program works:

For more information: (will appear on Website exactly as typed)

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